Medesthetics

JAN-FEB 2019

MedEsthetics—business education for medical practitioners—provides the latest noninvasive cosmetic procedures, treatment trends, product and equipment reviews, legal issues and medical aesthetics industry news.

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medestheticsmagazine.com | JANUARY/FEBRUARY 2019 27 REMOVING THE MASK OF MELASMA Melasma is one of the most challenging pigmentation concerns to treat. It has a high rate of recurrence and aggressive in-offi ce treatments carry a high risk PIH in patients with skin of color. Effective management often requires a combination of pre- scription topicals, strict sun protection and avoidance, and less aggressive in-offi ce procedures. "You have to be clear with the patient that melasma is chronic. There is no cure. We can manage it, but it will come back if we are not vigilant," says Dr. Roberts. The initial consultation is crucial in formulating a treatment plan. Physicians should take a family history, discuss pre-existing health conditions and medication use, and ask about the pa- tient's lifestyle. "If someone tells me that all the women in their family have melasma, I know that I'm dealing with a genetic propensity, not just lifestyle. And that tells me I'm going to have to go with the big guns," says Dr. Roberts. "Similarly, if a patient plays tennis every day from 1pm to 3pm or lives in the Sun Belt, they are going to be more diffi cult to clear." There are several medications that may cause or exacerbate hyperpigmentation. They include NSAIDs, such as ibuprofen, blood pressure medications, and birth control pills and hor- mones for menopausal symptoms. "Anything in the hormone family can cause hyperpigmentation," says Dr. Roberts. FIRST-LINE TREATMENTS Topical bleaching agents and sun protection are the fi rst-line treatments for melasma. "I begin with a topical bleaching agent—hydroquinone 4 percent—as well as sun protection," says Andrew F. Alexis, MD, Mount Sinai West Skin of Color Center in New York. "After a two month trial of topicals only, I then consider in-offi ce procedures in the form of superfi cial chemical peels or very conservative use of nonablative fractional lasers—my preferred device is the 1,927nm low-powered diode Clear + Brilliant Permea laser." Both Dr. Roberts and Dr. Alexis recommend Tri-Luma (Gal- derma), a prescription topical that combines 4 percent hydroqui- none with tretinoin and corticosteroid fl uocinolone acetonide. "I like hydroquinone. Nothing yet is proven to surpass it," says Dr. Roberts. "And the retinoids are great. There are University of Michigan studies going back to the 1990s showing that topical tretinoin by itself lightens skin. When you combine it with hy- droquinone and corticosteroids, you get the synergy of all three actives working together." Long-term use of hydroquinone is associated with the risk of exogenous ochronosis, so you do need to monitor the duration of therapy. "I typically use 4 percent as my standard, and patients can use it comfortably on a consecutive basis for six consecutive months, if warranted, followed by a six-month hiatus," says Dr. Alexis. "After six months of use. I transition the patient to non- HQ therapy, such as Lytera 2.0 (Skinmedica), azelaic acid, kojic acid or topical retinoids."

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